Diabetes Forecast

How do I handle mealtime insulin dosing for my child when I don’t know how much food she’s going to eat?


Robert Rapaport, MD, responds

Instead of dosing insulin before your child eats, deliver an injection after the meal.

What to Know

Infants and toddlers, as well as children who are sick, have unpredictable food intake. Often they’ll take a bite or two and decide they’re done. It’s not a big deal for kids without diabetes, but for those who take insulin, it can pose a risk. Without enough carbohydrate to cover the mealtime insulin dose, low blood glucose (hypoglycemia) can occur.

Symptoms of hypoglycemia include shakiness, nervousness or anxiety, sweating, irritability, confusion, rapid heartbeat, dizziness, and even seizures and loss of consciousness. Hypoglycemia can be hard to identify, especially in infants and toddlers who aren’t verbal. Looking for signs of altered behavior, such as fussiness or lethargy, and checking glucose often may help avoid this issue. Using a continuous glucose monitor (CGM) can also help you identify low and high glucose levels.

Find Out More

Insulin dosing in type 1 diabetes involves a basal (background, or long-acting insulin) and bolus (mealtime, or rapid-acting insulin) regimen via multiple daily injections or by use of an insulin pump. Mealtime insulin is usually delivered 15 to 20 minutes before a meal to meet the increase in glucose following a meal. Bolus dosing takes into account a person’s premeal glucose level in addition to the intended carbohydrate intake. However, infants and children don’t always eat everything on their plates.

That’s where after-meal dosing comes in. Here’s how it works: Check your child’s blood glucose level before the meal. Once your child has finished eating, dose insulin based on the premeal glucose level plus the grams of carbohydrate your child ate.

On rare occasions, an insulin dose may be split, with a portion delivered before a meal to account for any elevation in blood glucose and the rest delivered after a meal to cover carbohydrate intake. This is usually done on an individual basis as directed by your endocrinologist and isn’t routinely recommended. For children who enjoy eating slowly over hours, insulin pumps provide a square bolus setting, which delivers insulin evenly over a selected period of time instead of all at once. This is especially useful when, for instance, your child is attending a party or eating popcorn at the movies.

Half-unit insulin pens can provide flexibility in insulin dosing for young children. By delivering a smaller dose to account for less food eaten, they can lessen the risk of overtreatment and low blood glucose. 


Administer insulin following a meal in infants and children when food intake is uncertain due to age, eating habits, or illness. When in doubt regarding intake, a lower dose may prevent hypoglycemia. Take advantage of apps for carbohydrate counting and insulin calculations to improve diabetes management. Always contact your pediatric diabetes care team when unsure regarding insulin dosing. 

Robert Rapaport, MD, is a professor of pediatrics and chief of the Division of Pediatric Endocrinology and Diabetes at the Icahn School of Medicine at Mount Sinai Health System in New York City.



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